Pragmatic estimations of obstetric fistula in Bangladesh
Authors: Sayeba Akhter, AKM Fazlur Rahman
Journal: The Lancet Global Health (2022)

It is crucial to comprehend the scope of any health issue, particularly health needs assessments for effective health-care planning, especially in low-resource environments.1Wright J Williams R Wilkinson JR Development and importance of health needs assessment.BMJ. 1998; 316: 1310-1313Crossref PubMed Scopus (220) Google Scholar Although mortality from obstetric fistula in Bangladesh or other similar countries is not a concern, the condition carries health and social issues due to morbidity, disability, and social injustice, leading to abject quality of life.2USAID's Research for Decision MakersHow far is Bangladesh from eliminating obstetric fistula?.http://rdm.icddrb.org/how-far-is-bangladesh-from-eliminating-obstetric-fistula/Date accessed: June 30, 2022Google Scholar Therefore, having a reliable estimation of the magnitude of the obstetric fistula burden is essential for establishing an effective care strategy to manage it. As with many other diseases, identifying cases of obstetric fistula in a large community-based survey can be difficult. Verbal diagnosis using a series of signs and symptoms is frequently used to identify cases in household surveys; however, this method is incredibly limited in every instance. The Bangladesh Maternal Mortality and Health Care Survey's (BMMS)3National Institute of Population Research and TrainingInternational Centre for Diarrhoeal Disease Research, Bangladesh, MEASURE EvaluationBangladesh Maternal Mortality and Health Care Survey 2016: preliminary report.https://www.measureevaluation.org/resources/publications/tr-17-218.htmlDate accessed: June 29, 2022Google Scholar estimation of obstetric fistula uses some verbal questions to ascertain cases that lead to an overestimation of the prevalence of the condition. This confounds policy makers and programme planners to design a strategy for screening and clinical management of obstetric fistula cases. In The Lancet Global Health, Saifuddin Ahmed and colleagues offer a thorough analysis of the validated calculation of prevalence and burden of obstetric fistula in Bangladesh that makes use of the data from the national survey.4Ahmed S Curtis SL Jamil K et al.Obstetric fistula in Bangladesh: estimates from a national survey with clinical validation correction.Lancet Glob Health. 2022; 10: e1347-e1354Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar The authors used a novel method for reliable estimation of the prevalence of obstetric fistula that included an initial validation study in a population of 65 740 women, in which a survey questionnaire was followed by clinical examination of suspected cases; the use of estimated diagnostic values after correcting for verification bias; and the adjustment of the reported prevalence in the nationally representative survey, BMMS 2016.3National Institute of Population Research and TrainingInternational Centre for Diarrhoeal Disease Research, Bangladesh, MEASURE EvaluationBangladesh Maternal Mortality and Health Care Survey 2016: preliminary report.https://www.measureevaluation.org/resources/publications/tr-17-218.htmlDate accessed: June 29, 2022Google Scholar Other studies in this field can benefit from the clinical validation approaches for the credible estimation of obstetric fistula. The initial survey identified 67 potential cases of obstetric fistula; of them, 57 (85%) women completed the clinical examination, and 19 were confirmed as obstetric fistula cases. Ahmed and colleagues observed a low positive predictive value of 31·6% (95% uncertainty interval [UI] 19·2–46·2)in the validation study, suggesting that about two thirds of the self-reported cases were not actual obstetric fistula cases. According to Ahmed and colleagues’ other findings, actual obstetric fistula cases were accurately recognised by survey questions asked in the field, and true non-obstetric fistula cases were very unlikely to be misclassified as an obstetric fistula case (negative predictive value of 100% [approximately 100–100]). Obstetric fistula prevalence among women aged 15–49 years was reported to be 120 per 100 000 women (90% UI 108–134) in the nationwide survey, BMMS 2016. This prevalence rate was 38 per 100 000 women (25–58) after being adjusted for survey reporting validity. Overall, Ahmed and colleagues estimated that there are about 17 457 (90% UI 10 459–28 902) women aged 15–64 years living with obstetric fistula in Bangladesh, which is about a third of reported case estimation. Similar findings have been reported in other low-resource settings such as Ethiopia,5Ballard K Ayenachew F Wright J Atnafu H Prevalence of obstetric fistula and symptomatic pelvic organ prolapse in rural Ethiopia.Int Urogynecol J. 2016; 27: 1063-1067Crossref PubMed Scopus (22) Google Scholar Nepal,6Chen C Barry D Khatry SK et al.Validation of an obstetric fistula screening questionnaire in rural Nepal: a community-based cross-sectional and nested case-control study with clinical examination.BJOG. 2017; 124: 955-964Crossref PubMed Scopus (7) Google Scholar Nigeria,7Tuncalp O Isah A Landry E Stanton CK Community-based screening for obstetric fistula in Nigeria: a novel approach.BMC Pregnancy Childbirth. 2014; 14: 44Crossref PubMed Scopus (13) Google Scholar and India.8Swain D Parida SP Jena SK Das M Das H Prevalence and risk factors of obstetric fistula: implementation of a need-based preventive action plan in a South-eastern rural community of India.BMC Womens Health. 2020; 20: 40Crossref PubMed Scopus (10) Google Scholar Therefore, this paper offers some insight into how validation study findings might be applied to a reasonable estimation of certain health conditions that were determined in any national survey. However, it is important to do some cohort studies to estimate the incidence of obstetric fistula to help policy makers to design an efficient programme for clinical management of these cases routinely. Additionally, it is imperative to identify an effective community-based intervention for prevention of obstetric fistula as well as for detection, clinical care, and rehabilitation of existing cases. To help policy makers develop and deploy a comprehensive plan of action to fulfil the Government's commitment to eliminate obstetric fistula from Bangladesh, Ahmed and colleagues present a realistic estimate of the total number of cases. The plan will encompass finding these women who are quietly suffering in the community and bring them to facilities for quality management. More importantly, the strategy will concentrate on rehabilitation and reintegration of the women into society for a better quality of life. Ahmed and colleagues offer a methodological perspective for a pragmatic estimation of a health issue that not only applies to cases of obstetric fistula, but also to other situations that are similar. The study also conveys the message that the number of cases of obstetric fistula in Bangladesh assessed with questions from a large nationwide survey is more than three times higher than the estimate obtained with a clinically validated process. We declare no competing interests. Obstetric fistula in Bangladesh: estimates from a national survey with clinical validation correctionThe burden of obstetric fistula is still high in Bangladesh. Prevention and provision of surgical treatment to so many women will need coordinated efforts, planning, allocation of resources, and training of surgeons. Full-Text PDF Open Access